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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Progr m at Existing Facility New EH P ram an New F cilit <br />1 Facility ID Program Record ID <br /> CO <br />ci Facility Address ) 6 416 0 6-7c_Aellon Va, Ruu yop rff 61 -330 <br /> <br />(Please check the appropriate description and specify size, numberkiof units an ertinent information.) <br />0 with Food Preparation <br />3 0 w/Meat Market only <br /> Vehicle Type <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only <br />P. Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Food Handlers Course required: YES U No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br /> Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />License # <br />Vehicle Type <br />License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200)-------->-Tons Generated Per Year <br />Tiered Permitting Facility --> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Ja Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel—Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility n Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm—Maximum number of birds <br /> Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Fa <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-T ility-S pgle Use (4120) p :nt Mobile Fac' t 4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br /> <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled <br />Transfer Station El Veterinary Clinic <br />Iumber of <br />Vehic e # <br />its <br />ud /Ash <br />A Landfill t <br />Farm/Ranch Cleanup Site <br />License # Capacity <br />0 Chemical Toilets <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (It of Units) <br />Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Common Storage Facility 0 2-10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />T Day Ph 707—l1gir cgD Night Ph 767-Y -sg91 .0 CONTACT PERSON <br />PROGRAM ELEMENT FEE <br />INSPECTOR # s PERMIT VALID <br />AMOUNT PAID 0 Check # <br />0 Cash REVE.% ED BY <br />0 Surcharge FEE 0 Other FEE <br />48-02-034 <br />1/23/13 C <br />s ...It to • \ 2 0 Food Ha <br /> Date NSW INVOICE # <br />ACCOUNTING OFFICE B ate <br />dler <br />1/ <br />STERFILE RECORD INFORMATION PINK